Perceived vulnerability to disease and children's COVID behavioral response: The role of health consciousness and family financial status.

This study investigated the impact of family financial status on Chinese children's health-related traits and their behavior in controlling COVID-19. When the children were 7 years old, their guardians provided information on family financial status. When the children reached 10 years old, they completed questionnaires concerning their own health consciousness and health status. At age 11, during the COVID-19 pandemic in 2020, they filled out questionnaires on perceived vulnerability to disease and disease control behavior. The findings revealed that higher health consciousness is associated with better health, particularly among children from financially challenged families. Additionally, a greater perception of vulnerability to disease is linked to increased COVID-19 control behaviors, particularly in children with high health consciousness in affluent families. These results contribute to our understanding of how children's personal health-related traits and family financial status interact to shape their response to the COVID-19 pandemic.

Battle to Survive: The Association Between Accountability and Chinese Local Government Response to COVID-19.

China's ability to sustain the zero-COVID strategy over three years has garnered global attention, but little is known about the factors contributing to its long-term adherence. Based on the political promotion tournament model, this article theorizes that China's strict administrative accountability system, which tied local officials' career prospects to their performance in crucial policy goals, incentivized local governments to sustain COVID-19 policies. Using data from the Oxford COVID-19 Government Response Tracker and major official Chinese media outlets, we performed interrupted time series analysis (ITSA) to examine whether the accountability events affected the local government's COVID-19 responses. Noticeably, our analyses found that from May 4, 2020, to September 30, 2022, when an accountability event happened, officials in the affected (local effects) and unaffected (spillover effects) provinces all increased their containment responses and decreased their economic support responses. This is true even for provinces without new localized outbreaks. The effects of accountability events increased with decreasing geographical distance. These findings remain consistent after several robustness checks. The administrative accountability system is a key institutional factor in implementing China's zero-COVID strategy, which contributed to the global literature about the pandemic policy process in centralized countries.

A regional learning health system of congregate care facilities for COVID-19 response.

Introduction: The COVID-19 pandemic disproportionately affected congregate care (CC) facilities due to communal living, presence of vulnerable populations, inadequate preventive resources, and limited ability to respond to the pandemic's rapidly evolving phases. Most facilities function independently and are not organized for collaborative learning and operations. Methods: We formed a learning health system of CC facilities in our 14-county metropolitan region, coordinated with public health and health care sectors, to address challenges driven by COVID-19. A CC steering committee (SC) was formed that represented diverse institutions and viewpoints, including skilled nursing facilities, transitional care facilities, residential facilities, prisons, and shelters. The SC met regularly and was guided by situational awareness and systems thinking. A regional CC COVID-19 dashboard was developed based on publicly available data and weekly data submitted by participating facilities. Those experiencing outbreaks or supply shortages were quickly identified. As the pandemic progressed, the role of the SC shifted to address new and forecasted needs. Results: Over 60 facilities participated in data sharing. The SC shared new guidelines, regulations, educational material, and best practices with the participating facilities. Information about testing sites, supplies, vaccination rollout, and facilities that had the capacity to accept COVID-19 patients was regularly disseminated. The SC was able to direct resources to those facilities experiencing outbreaks or supply shortages. Conclusions: A novel learning health system of regional CC facilities enabled preparedness, situational awareness, collaboration, and rapid dissemination of best practices across pandemic phases. Such collaborative efforts can play an important role in addressing other public and preventive health challenges.

Healthcare workers' knowledge, attitude and practices on infection prevention and control in the context of the COVID-19 pandemic at the Faranah regional hospital and associated healthcare centers, Guinea.

BACKGROUND: In response to the COVID-19 pandemic, WHO launched a strategic preparedness and response plan, outlining public health measures to support countries worldwide. Healthcare workers have an increased risk of becoming infected and their behaviour regarding infection prevention and control (IPC) influences infection dynamics. IPC strategies are important across the globe, but even more in low-resource settings where capacities for testing and treatment are limited. Our study aimed to assess and implement COVID-19 pandemic preparedness and response measures in Faranah, Guinea, primarily focusing on healthcare workers' IPC knowledge, attitude and practice (KAP). METHODS: The study was conducted between April 2020 and April 2021 assessing IPC pandemic preparedness and response measures such as healthcare workers' KAP, alcohol-based handrub (ABHR) consumption and COVID-19 triaging in the Faranah Regional Hospital and two associated healthcare centres. The assessment was accompanied by IPC training and visual workplace reminders and done in pre- and post- phases to evaluate possible impact of these IPC activities. RESULTS: The overall knowledge score in the Faranah Regional Hospital was 32.0 out of 44 at baseline, and did not change in the first, but increased significantly by 3.0 points in the second follow-up. The healthcare workers felt closer proximity to SARS-CoV-2 overtime in addition to higher stress levels in all study sites. There was significant improvement across the observed triaging practices. Hand hygiene compliance showed a significant increase across study sites leading to 80% in Faranah Regional Hospital and 63% in healthcare centers. The average consumption of ABHR per consultation was 3.29 mL with a peak in February 2020 of 23 mL. CONCLUSION: Despite increased stress levels among HCWs, the ongoing IPC partnership well prepared the FRH in terms of triaging processes with a stronger impact on IPC practice than on theoretical knowledge. Throughout the pandemic, global shortages and surges in consumption did not affect the continuous ABHR provision of the FRH. This highlights local ABHR production as a key pandemic preparedness strategy.

Ku Like Kakou: Utilizing a Community-led Model of Collaboration to Respond to the COVID-19 Pandemic.

The outbreak of COVID-19 in 2020 brought significant challenges for Native Hawaiians (NH), Pacific Islanders (PI), and other communities of color worldwide. Rapidly increasing rates of infection and transmission of the virus in Native Hawaiian and Pacific Islander (NHPI) communities and incomplete or unavailable data signaled to Hawai'i's leaders that advocacy and action needed to take place to minimize the impact of COVID-19. The Native Hawaiian and Pacific Islander Response, Recovery, and Resilience team (NHPI 3R Team) emerged from an effort to lead and fill gaps in response to COVID-19. Through the swift, intentional, and collaborative work of the team and its partners, NHPI communities and the entities that serve them were better equipped to navigate the pandemic, improve health outcomes, and contribute to a reduction in the number of infections, a rise in vaccination uptake, and an increase in NH and PI representation on various levels of government agencies. As the world shifts its focus from COVID-19 to broader health topics, the NHPI 3R Team will continue to serve as a hub for the exchange of resources and a model of community-led work that can be used to tackle issues like COVID-19 and beyond.

Use of a toll-free call center for COVID-19 response and continuity of essential services during the lockdown, Greater Kampala, Uganda, 2020: a descriptive study.

Introduction: on March 21, 2020, the first case of COVID-19 was confirmed in Uganda. A total lockdown was initiated on March 30 which was gradually lifted May 5-June 30. On March 25, a toll-free call center was organized at the Kampala Capital City Authority to respond to public concerns about COVID-19 and the lockdown. We documented the set-up and use of the call center and analyzed key concerns raised by the public. Methods: two hotlines were established and disseminated through media platforms in Greater Kampala. The call center was open 24 hours a day and 7 days a week. We abstracted data on incoming calls from March 25 to June 30, 2020. We summarized call data into categories and conducted descriptive analyses of public concerns raised during the lockdown. Results: among 10,167 calls, two-thirds (6,578; 64.7%) involved access to health services, 1,565 (15.4%) were about social services, and 1,375 (13.5%) involved COVID-19-related issues. Approximately one-third (2,152; 32.7%) of calls about access to health services were requests for ambulances for patients with non-COVID-19-related emergencies. About three-quarters of calls about social services were requests for food and relief items (1,184; 75.7%). Half of the calls about COVID-19 (730; 53.1%) sought disease-related information. Conclusion: the toll-free call center was used by the public during the COVID-19 lockdown in Kampala. Callers were more concerned about access to essential health services, non-related to COVID-19 disease. It is important to plan for continuity of essential services before a public health emergency-related lockdown.

The Scabbard of Excalibur: An Allegory on the Role of an Efficient and Effective Healthcare System under Universal Health Coverage during the Pandemic Response.

During the COVID-19 pandemic, while some countries succeeded in reducing their rate of death after SARS-CoV-2 infection via vaccination by the end of 2021, some of them also faced hospital capacity strain, leading to social anxiety about delays in the diagnosis and treatment of patients with other diseases. This essay presents an allegory to explain the situation during the COVID-19 pandemic. Through an allegory and Le Morte d'Arthur (Arthur's Death), this essay indicates that "the scabbard of Excalibur" that we are looking for is an efficient and effective healthcare system that can diagnose patients who might become severely ill due to COVID-19 and to treat them without hospital capacity strain. In Le Morte d'Arthur, the scabbard of Excalibur was lost, and we have not been able to find any alternatives to end the COVID-19 pandemic. We can choose a future in which "the scabbard of Excalibur" exists, providing a different ending for the next pandemic.

HERA-lding More Integration in Health? Examining the Discursive Legitimation of the European Commission's New Health Emergency Preparedness and Response Authority.

CONTEXT: Since COVID-19, the European Commission (EC) has sought to expand its activities in health through the development of a European Health Union and within it the Health Emergencies Preparedness and Response Authority (HERA). METHODS: The authors applied a discourse analysis to documents establishing HERA to investigate how the EC legitimated the creation of this institution. They focused on how it framed health emergencies, how it framed the added value of HERA, and how it linked HERA to existing EU activities and priorities. FINDINGS: Their analysis demonstrates that security-based logics have been central to the EC's legitimation of HERA in alignment with a "securitization of health" occurring worldwide in recent decades. This legitimation can be understood as part of the EC's effort to promote future integration in health in the absence of new competences. CONCLUSIONS: Securitization has helped the EC raise its profile in health politically without additional competences, thereby laying the groundwork for potential future integration. Looking at the discursive legitimation of HERA sheds light not only on whether the EC is expanding its health powers but also how it strategizes to do so. HERA, while constrained, allows the EC to further deepen security-driven integration in health.

Kenya's Experience: Factors Enabling and Impeding the COVID-19 Response.

This case study describes the country-level response to the COVID-19 pandemic in Kenya between February 2020 and May 2021. We organize the presentation of COVID-19 response strategies across the five stages of (a) engagement, (b) assessment, (c) planning, (d) action/implementation, and (e) evaluation. We describe the participatory monitoring and evaluation (M&E) process implemented in collaboration with the WHO Regional Office for Africa Monitoring and Evaluation Team. The M&E system was used to organize and make sense of emerging data regarding specific response activities and changing COVID incidence. We share the results of that collaborative sensemaking, with particular attention to our analysis of the factors that facilitated and those that impeded our pandemic response. We conclude with lessons learned and practical implications from Kenya's experience to help guide future country-level responses to rapidly changing public health crises.

Improving testing capacity for COVID-19: experiences and lessons from Senegal, Uganda, Nigeria, and the Democratic Republic of Congo.

Background: African countries leveraged testing capacities to enhance public health action in response to the COVID-19 pandemic. This paper describes experiences and lessons learned during the improvement of testing capacity throughout the COVID-19 response in Senegal, Uganda, Nigeria, and the Democratic Republic of the Congo (DRC). Methods: The four countries' testing strategies were studied using a mixed-methods approach. Desk research on COVID-19 testing strategies was conducted and complemented by interviewing key informants. The findings were synthesized to demonstrate learning outcomes across the four countries. Results: The four countries demonstrated severely limited testing capacities at the onset of the pandemic. These countries decentralized COVID-19 testing services by leveraging preexisting laboratory systems such as PCR and GeneXpert used for the diagnosis of tuberculosis (TB) to address this gap and the related inequities, engaging the private sector, establishing new laboratories, and using rapid diagnostic tests (RDTs) to expand testing capacity and reduce the turnaround time (TAT). The use of digital platforms improved the TAT. Testing supplies were sourced through partners, although access to global markets was challenging. Case detection remains suboptimal due to high costs, restrictive testing strategies, testing access challenges, and misinformation, which hinder the demand for testing. The TAT for PCR remained a challenge, while RDT use was underreported, although Senegal manufactured RDTs locally. Key findings indicate that regionally coordinated procurement and manufacturing mechanisms are required, that testing modalities must be simplified for improved access, and that the risk-based testing strategy limits comprehensive understanding of the disease burden. Conclusion: Although testing capacities improved significantly during the pandemic, case detection and access to testing remained suboptimal. The four countries could benefit from further simplification of testing modalities and cost reduction. Local manufacturing and pooled procurement mechanisms for diagnostics are needed for optimal pandemic preparedness and response.

Using a web platform for equitable distribution of COVID-19 monoclonal antibodies: a case study in resource allocation.

While medical countermeasures in COVID-19 have largely focused on vaccinations, monoclonal antibodies (mAbs) were early outpatient treatment options for COVID-positive patients. In Minnesota, a centralized access platform was developed to offer access to mAbs that linked over 31,000 patients to care during its operation. The website allowed patients, their representative, or providers to screen the patient for mAbs against Emergency Use Authorization (EUA) criteria and connect them with a treatment site if provisionally eligible. A validated clinical risk scoring system was used to prioritize patients during times of scarcity. Both an ethics and a clinical subject matter expert group advised the Minnesota Department of Health on equitable approaches to distribution across a range of situations as the pandemic evolved. This case study outlines the implementation of this online platform and clinical outcomes of its users. We assess the impact of referral for mAbs on hospitalizations and death during a period of scarcity, finding in particular that vaccination conferred a substantially larger protection against hospitalization than a referral for mAbs, but among unvaccinated users that did not get a referral, chances of hospitalization increased by 4.1 percentage points.

A Screening Program for SARS-CoV-2 among University of Hawai'i at Manoa Residence Hall Students during the COVID-19 Pandemic.

The University of Hawai'i at Manoa (UHM) created a COVID-19 pandemic team to collaborate, plan, and mitigate the spread of COVID-19 across the campus. The purpose of this study was to identify asymptomatic and pre-symptomatic cases of SARS-CoV-2 among unvaccinated UHM residence hall students during 3 distinct intervals (semesters) within the COVID-19 pandemic. Supervised self-administered nasal swab testing samples were collected from unvaccinated UHM residence hall students and sent to a clinical laboratory for COVID-19 RT-PCR testing to detect SARS-CoV-2. Positive cases were contacted and placed in isolation while contact tracing was initiated. The screening program performed 2219 tests on 725 unique persons with the identification of COVID-19 infections in 38 asymptomatic unvaccinated students and an additional 10 cases through contact tracing. A positive correlation existed between the screening program case numbers and the state of Hawai'i 7-day average positive cases as demonstrated with a Pearson coefficient of 0.79 and P<.001. The COVID-19 positivity rate was greater during Spring Semester 2022 compared to both Spring Semester 2021 (P<.001) and Fall Semester 2021 (P <.001). This program served as a component ofa larger strategy to mitigate the effects of the COVID-19 pandemic on the UHM campus. Additional benefits of the program included opportunities to increase COVID-19 awareness, enact health policy measures, evolve to meet changing pandemic demands, and maintain a safe UHM campus.

COVID-19 Health Education Activities: An Analysis of a National Sample of Certified Health Education Specialists (CHES®/MCHES®) in Response to the Global Pandemic.

The National Commission of Health Education Credentialing, Inc. (NCHEC) created the Category 1 COVID-19 Claim Form Opportunity to document how Certified Health Education Specialists (CHES®) and Master Certified Health Education Specialists (MCHES®) assisted communities during the COVID-19 pandemic. Using data submitted by CHES®/MCHES® (n = 3,098 claim forms), the purpose of this study was to (a) describe the settings where CHES® and MCHES® completed their pandemic work and (b) assess differences in the type of pandemic work completed by CHES® compared with MCHES® based on specific Areas of Responsibility (AOR) for Health Education Specialists. Findings showed that CHES® and MCHES® engaged in seven AOR during the pandemic, with the largest proportion of CHES® (n = 859; 33%) and MCHES® (n = 105; 21.9%, documenting COVID-19-related activities in health departments. CHES® reported higher engagement than MCHES® in activities such as COVID-19 reporting/tracking, χ2 (1, N = 3,098) = 27.3, p < .001; outbreak response, χ2 (1, N = 3,098) = 4.3, p = .039; and vaccination, χ2 (1, N = 3,098) = 5.2, p = .023. Conversely, MCHES® reported higher participation than CHES® in screening/testing, χ2 (1, N = 3,098) = 174.2, p < .001; administration of budgets/operations, χ2 (1, N = 3,098) = 30.1, p < .001; and adapting educational activities at college/universities, χ2 (1, N = 3,098) = 46.1, p < .001. CHES® were more likely than MCHES® to indicate working in all AOR except for Area 2-Plan Health Education/Promotion. Results support that employer-verified health education skills in all AOR were transferable during COVID-19, especially for CHES® employed within state/county health departments.

Proposal for a national diagnostics action plan for the United States.

Providing a definitive diagnostic test in a disease emergency is critical to limit pathogen spread, develop and deploy medical countermeasures, and mitigate the social and economic harms of a serious epidemic. While major accomplishments have accelerated test development, expanded laboratory testing capacity, and established widespread point-of-care testing, the United States does not have a plan to rapidly respond, to develop, manufacture, deploy, and sustain diagnostic testing at a national scale. To address this gap, we are proposing a National Diagnostics Action Plan that describes the steps that are urgently needed to prepare for future infectious disease emergencies, as well as the actions we must take at the first signs of such' events. These recommendations require substantial collaboration between the US government (USG) and the private sector to solve a series of challenges now, as well as to prepare for the massive and rapid scale-up of laboratory and point-of-care test development and testing capacity in future emergencies. The recommendations include establishing pre-event contracts; ensuring rapid access to clinical samples; creating a permanent public-private testing coordinating body to allow for rapid information sharing and improved cooperation among the USG, test developers, and clinical laboratories; and accelerating testing rollout at the beginning of an event-and thus, the effective public health management of a disease crisis.

Was it really different? COVID-19-pandemic period in long-term recreation monitoring - A case study from Polish forests.

The COVID -19 pandemic posed serious challenge for securing public health worldwide. Public health preparedness and restrictions put in place impacted many aspects of human life, including recreational activities and access to outdoor recreational destinations. Green spaces have become one of the few sources of resilience during the coronavirus crisis due to their restorative effects on psychophysical health and community well-being. The aim of this study is to analyse the impact of the COVID -19 pandemic on forest visitation. The results are based upon long-term visitor data acquired via pyroelectric sensors (Eco-Counter) in three forest districts located in Poland (Browsk, Gdansk & Kozienice Forest Districts). The analysis covers the period between January 01, 2019 and December 31, 2020 and the results confirm changes in recreational use in the studied forest areas during the pandemic compared to the preceding year. However, observed changes in forest visitation vary by pandemic period and study area. The ban on access to forest areas significantly reduced the number of forest visits in all studied areas. The number of visits to sub-urban forests (Gdansk Forest District) and to remote nature-based tourist destinations (Browsk Forest District) increased in the later pandemic periods, especially in the summer months of 2020, while it remained the same in a popular nearby recreation area: Kozienice Forest District. There were only minor temporal shifts in the distribution of weekly and daily visits. The results are important for public health preparedness planning in crisis situations and for provisioning conditions supporting societal health and well-being. Objective data on forest visits are necessary for successful management of forest areas and surrounding amenities. More cross-sector collaboration and public participation would be desirable to create sustainable, resilient, and liveable spaces for the society. Management Implications: •Long-term visitation monitoring is crucial for successful management of outdoor recreation destinations and their catchment areas.•Objective numbers concerning forest visitation from the pre-pandemic and COVID-19 pandemic period allow observing trends and making fact-based management decisions during period of crisis.•Changes in the investigated three forest study areas in Poland were not homogenous, which implies the necessity of systematic visitor monitoring in multiple destinations, in order to cover different types of forest areas and also local diversity in recreational use.•More intersectoral, interdisciplinary and transdisciplinary exchange would be desirable to better integrate existing on-site visitor monitoring data into decision making processes related to forest management, urban planning, transportation, tourism and public health.

Epidemiological intelligence community network intervention: a community response for COVID-19 community transmission.

BACKGROUND: Expanding and providing access to early detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through testing community-based strategies among socially vulnerable communities (SVC) are critical to reducing health disparities. The Epidemiological Intelligence Community Network (EpI-Net) community-based intervention sought to increase coronavirus 2019 (COVID-19) testing uptake and prevention practices among SVC in Puerto Rico (PR). We evaluated EpI-Net's community leaders' capacity-building component by assessing pre-post COVID-19 public health workshops' tests' score changes and satisfaction among trained community leaders. METHODS: A total of 24 community leaders from SVC in PR have completed four community workshops. Pre- and post-assessments were completed as part of the health promotors training program to evaluate participants' tests score changes and satisfaction outcomes. RESULTS: Preliminary results showed: (1) high intervention retention levels of community leaders (85.7% acceptance rate); (2) change in post-test scores for community engagement strategies (p = 0.012); (3) change in post-test educational scores in COVID-19 prevention practices (p = 0.014); and (4) a change in scores in public health emergency management strategies (p < 0.001). CONCLUSIONS: The overall workshop satisfaction was 99.6%. Community leaders have shown the importance of community capacity building as a key component for intervention feasibility and impact. TRIAL REGISTRATION: Our study was retrospectively registered under the ClinicalTrial.gov ID NCT04910542.

The use of innovative approaches to strengthen health system resilience during the COVID-19 pandemic: case studies from selected Commonwealth countries.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. The COVID-19 pandemic has exposed the vulnerabilities and limitations of many health systems and underscored the need for strengthening health system resilience to make and sustain progress toward Universal Health Coverage (UHC), global health security and healthier populations in tandem. In response to the COVID-19 pandemic, Commonwealth countries have been practicing a combination of innovative integrated approaches and actions to build health systems resilience. This includes utilizing digital tools, improvements in all-hazard emergency risk management, developing multisectoral partnerships, strengthening surveillance and community engagement. These interventions have been instrumental in strengthening national COVID-19 responses and can contribute to the evidence-base for increasing country investment into health systems resilience, particularly as we look toward COVID-19 recovery. This paper gives perspectives of five Commonwealth countries and their overall responses to the pandemic, highlighting practical firsthand experiences in the field. The countries included in this paper are Guyana, Malawi, Rwanda, Sri Lanka, and Tanzania. Given the diversity within the Commonwealth both in terms of geographical location and state of development, this publication can serve as a useful reference for countries as they prepare their health systems to better absorb the shocks that may emerge in future emergencies.

COVID-19 surveillance in Democratic Republic of Congo, Nigeria, Senegal and Uganda: strengths, weaknesses and key Lessons.

INTRODUCTION: As part of efforts to rapidly identify and care for individuals with COVID-19, trace and quarantine contacts, and monitor disease trends over time, most African countries implemented interventions to strengthen their existing disease surveillance systems. This research describes the strengths, weaknesses and lessons learnt from the COVID-19 surveillance strategies implemented in four African countries to inform the enhancement of surveillance systems for future epidemics on the continent. METHODS: The four countries namely the Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda, were selected based on their variability in COVID-19 response and representation of Francophone and Anglophone countries. A mixed-methods observational study was conducted including desk review and key informant interviews, to document best practices, gaps, and innovations in surveillance at the national, sub-national, health facilities, and community levels, and these learnings were synthesized across the countries. RESULTS: Surveillance approaches across countries included - case investigation, contact tracing, community-based, laboratory-based sentinel, serological, telephone hotlines, and genomic sequencing surveillance. As the COVID-19 pandemic progressed, the health systems moved from aggressive testing and contact tracing to detect virus and triage individual contacts into quarantine and confirmed cases, isolation and clinical care. Surveillance, including case definitions, changed from contact tracing of all contacts of confirmed cases to only symptomatic contacts and travelers. All countries reported inadequate staffing, staff capacity gaps and lack of full integration of data sources. All four countries under study improved data management and surveillance capacity by training health workers and increasing resources for laboratories, but the disease burden was under-detected. Decentralizing surveillance to enable swifter implementation of targeted public health measures at the subnational level was a challenge. There were also gaps in genomic and postmortem surveillance including community level sero-prevalence studies, as well as digital technologies to provide more timely and accurate surveillance data. CONCLUSION: All the four countries demonstrated a prompt public health surveillance response and adopted similar approaches to surveillance with some adaptations as the pandemic progresses. There is need for investments to enhance surveillance approaches and systems including decentralizing surveillance to the subnational and community levels, strengthening capabilities for genomic surveillance and use of digital technologies, among others. Investing in health worker capacity, ensuring data quality and availability and improving ability to transmit surveillance data between and across multiple levels of the health care system is also critical. Countries need to take immediate action in strengthening their surveillance systems to better prepare for the next major disease outbreak and pandemic.